Participation in Adults Post Total Knee Replacement

Transcription

1 Participation in Adults Post Total Knee Replacement Jessica Maxwell, PT, DPT, OCS Boston University College of Health and Rehabilitation Sciences: Sargent College Boston University Medical Center

2 Learning Objectives Review the prevalence and incidence of knee replacements in the U.S. Present the current evidence on knee replacement outcomes aside from participation Present current evidence on participation outcomes after knee replacement Discuss future areas for research

3 Background Rates of total knee replacement skyrocketing Over 3.5 million annually in U.S. by Figure adapted from, 1 Kurtz, 2007

4 Significance of Increased knee replacement utilization Projected annual costs of $49 billion by Increase from $14.6 billion in 2004 JAMA- 2012: Need for increased study and tracking of health outcomes of knee replacement 2 Public health concern 1 Kim, 2008; 2 Slowver, et al; JAMA 2012

5 What do we already know about knee replacement outcomes?

6 How are knee replacement outcomes measured? Outcome Tools: Western Ontario McMaster Osteoarthritis Index (WOMAC) Late Life Disability Index (LLDI) Thresholds of change or status: Minimal Clinically Important Difference/Improvement (MCII) 1 Patient Acceptable Symptom State (PASS) 2 Escobar et al, 2007; Escobar et al, 2012

7 PAIN Overall there is a significant reduction in pain after knee replacement 1 Approximately 50% in first year Persistent Pain Systematic review of 11 studies approximately 20% of patients have long-term persistent pain 2 1 Bachmeier, 2011; 2 Beswick, et al, 2012

8 PHYSICAL FUNCTION Improvement in physical function occurs after knee replacement 1 Systematic review of 62 studies Mean improvement of 28/100 points on WOMAC 1 Kane et al, 2005;

9 PHYSICAL FUNCTION Persistent physical function limitations Estimates range from 10-30% of patients 21% at 2 years following knee replacement 1 71% met the Patient Acceptable Symptom State for function after knee replacement 2 Study of patient satisfaction found 81% satisfied with functional activities 3 1 Singh et al 2010, 2 Maxwell et al, in submission; 3 Bourne et al, 2010

10 But what about PARTICIPATION?

11 Participation matters to knee replacement patients Patient concerns about participation status increased throughout the 6 week period following knee replacement 1 Considering return to these roles (going shopping, participating in hobbies ) Items related to participation (driving, walking outdoors) ranked among the highest in importance among subjects pre- and 6 months post-knee replacement 2 1 Rastogi et al, Wright et al, 2010

12 How is knee replacement related to participation? George et al (2008) studied ADL and IADL changes Knee replacement group and knee osteoarthritis group E.g. IADLs: preparing meals, housework, shopping Knee replacement group improved while the nonknee replacement group declined Performing personal shopping: improved 6% for knee replacement subjects, vs. 1.7% decline for OA subjects

13 How is knee replacement related to participation? Davis et al (2011) found mean improvements in participation among those with knee replacement Measured participation with LLDI and Calderdale Community Mobility Scale Subjects improved in participation 27% from 3 to 12 months post-knee replacement Pre-knee replacement participation influenced postknee replacement participation Improvement in participation occurred later than improvements in pain and function

14 Do people with knee replacements experience participation restrictions? As with pain and function, there appears to be an improvement in mean participation. Is there similarly a proportion of subjects that are experiencing participation restrictions after knee replacement?

15 Frequency and Predictors of Participation Restriction Following Knee Replacement Maxwell JL 1, Keysor JJ 1, Neogi T 1, Niu J 1, Nevitt MC 3, Singh J 3, Frey-Law L 4, Felson DT 1 1 Boston University, Boston, MA; 2 University of California, San Francisco; 3 University of Alabama, Birmingham; 4 University of Iowa, Iowa City OARSI, 2012

16 Prevalence of Participation Restrictions To explore the prevalence of home and community participation restrictions among persons at least 1 and 2 years after a knee replacement.

17 MOST Study 3026 persons recruited from community in Iowa and Alabama with risk factors for knee osteoarthritis Clinic visits at 0, 30, 60, 84 months Subsample of subjects with knee replacement at least one year prior to assessment of participation LLDI- Instrumental subscale of the Limitation domain used to measure participation Considered score of <69/100 to have participation restricted

18 Study Sample Subjects demographic and 1 year post-knee replacement clinical factors (n=218) Maxwell, et al, OARSI, 2012

19 Prevalence of Participation Restriction Proportions of subjects with participation restrictions pre- knee replacement and post- knee replacement Independent Variable % of Subjects with Participation Restrictions Pre-knee replacement (n=218) 1 year post-knee replacement (n=218) p-value Total p=.12 Sex: Women p=.26 Men p=.25 Race: White p=.29 Other p=.13 Age at knee replacement: <65 years p= years p= years p=.13 Maxwell, et al, OARSI, 2012

20 Prevalence of Participation Restriction Proportions of subjects with participation restrictions pre- knee replacement and post- knee replacement Independent Variable % of Subjects with Participation Restrictions Pre-knee replacement (n=218) 1 year post-knee replacement (n=218) p-value Total p=.12 Sex: Women p=.26 Men p=.25 Race: White p=.29 Other p=.13 Age at knee replacement: <65 years p= years p= years p=.13 Maxwell, et al, OARSI, 2012

21 Prevalence of Participation Restriction Proportions of subjects with participation restrictions pre- knee replacement and post- knee replacement Independent Variable % of Subjects with Participation Restrictions Pre-knee replacement (n=218) 1 year postknee replacement (n=218) p-value Total p=.12 Sex: Women p=.26 Men p=.25 Race: White p=.29 Other p=.13 Age at knee replacement: <65 years p= years p= years p=.13 Maxwell, et al, OARSI, 2012

22 Prevalence of Participation Restriction Proportions of subjects with participation restrictions pre- knee replacement and post- knee replacement Independent Variable % of Subjects with Participation Restrictions Pre-knee replacement (n=218) 1 year postknee replacement (n=218) p-value Total p=.12 Sex: Women p=.26 Men p=.25 Race: White p=.29 Other p=.13 Age at knee replacement: <65 years p= years p= years p=.13

23 Conclusions-Prevalence of participation restrictions Non-Whites have a higher proportion of participation restrictions pre-knee replacement than Whites The youngest subjects had somewhat higher proportions with participation restrictions pre-knee replacement, and their post-knee replacement participation restrictions was significantly lower. Older subjects report less participation restrictions pre-knee replacement but have increased % of participation restrictions after knee replacement Maxwell, et al, OARSI, 2012

24 What is driving these restrictions? What demographic and clinical factors are associated with participation restrictions among persons with a knee replacement at least 1 year earlier?

25 Does Age Matter? Subjects with participation restrictions pre-knee replacement: Not Participation Restricted Post-knee replacement Participation Restricted Post-knee replacement Age < Age Age

26 Prevalence Ratios of post- knee replacement participation restriction Independent Variable Unadjusted, PR (95%CI) Adjusted PR (95% CI) Sex (ref=men) 1.6 (0.8, 3.0) 1.8 (0.7, 2.7) Race (ref= White) 2.0 (0.9, 4.4) 1.9 (0.8, 4.5) Age at knee replacement: < 65 yrs. (n=92) Reference Reference (n=101) 1.0 (0.5, 1.9) 1.1 (0.6, 2.1) 75+ (n=25) 1.9 (0.8, 4.7) 2.2 (0.9, 5.7) Educational Attainment (ref=>hs) 1.4 (0.4, 4.5) 1.2 (0.4, 4.0) Depressive Symptoms (ref 16) 4.9 (2.2, 11) 4.5 (2.0, 10.3) Quadriceps Strength: strongest tertile Reference Reference middle tertile 1.1 (0.5, 2.3) 1.0 (0.5, 2.3) weakest tertile 1.4 (0.6, 3.0) 1.3 (0.6, 2.8) Post-knee replacement pain in the 5.1 (1.8, 14.4) 7.0 (2.2, 22.7) ipsilateral (knee replacement) knee (ref <10/20) Post-knee replacement pain in contralateral 5.6 (1.9, 16.8) 5.3 (1.6, 16.9) knee (ref <10/20) Number of knees replaced (ref=1) 1.0 (0.5, 1.9) 1.0 (0.6, 2.0) Body Mass Index (ref < 30) 1.1 (0.6, 1.9) 1.1(0.6, 2.1) Pre-knee replacement WOMAC Physical 1.1 (1.0, 1.1) 1.1 (1.0, 1.1) Function Comorbidities 1.1 (0.9, 1.3) 1.0 (0.8, 1.3) Maxwell, et al, OARSI, 2012

27 Conclusions-Predictors of participation restrictions after knee replacement Depressive symptoms Pain in either knee Oldest age group? Potential Intervention targets?

28 Limitations Cross Sectional Quantitative analysis may not fully inform us about the reasons for participation restriction in this patient population. Need to assess other factors not included in measurement tools or measured at clinical visits Limited to those with knee replacement. Can t determine effect of knee replacement on participation without a comparison group

29 The Effect of Knee Replacement on Participation Restrictions: The Multicenter Osteoarthritis Study Maxwell JL 1, Niu J 1, Yang T 1, Keysor, JJ 1, Neogi T 1, Nevitt MC2, Singh J3, Frey-Law L4 and Felson DT1 1Boston University, Boston, MA; 2University of California, San Francisco; 3University of Alabama, Birmingham; 4University of Iowa, Iowa City Maxwell, ACR, 2012

30 Aims Determine whether the proportions with participation restrictions are similar among knee replacement subjects and a matched group of people without knee replacement Determine the effect of knee replacement status on participation as compared to a group with symptomatic OA but without knee replacement

31 Methods We compared those with knee replacement to a matched group of persons with symptomatic knee OA (SxOA) using propensity score methods to reduce confounding by indication Estimates probability of each subject of having a knee replacement, given their covariates Increase similarity between two groups 1 Maxwell, et al, ACR, 2012

32 Demographic and pre-index clinical variables by knee replacement status group Unmatched Whole Sample (Crude) Propensity Score** Matched Sample Variable knee replacement subjects (n=267) Non- knee replacement subjects (n=1255) knee replacement subjects (n=237)* Non-knee replacement subjects (n=237) Age, years, mean 67.9 (7.6) 66.5 (8.1) 68.0 (7.6) 67.7 (7.9) (SD) % Female % White BMI, kg/m 2, mean (SD) 32.6 (7.0) 32.1 (6.5) 32.1 (6.6) 32.2 (6.5) Depressive score, range 0-16, mean (SD) % with 1 Comorbidity Knee pain, range 0-20, mean (SD) WOMAC Function, mean (SD) % with Participation Restrictions 8.4 (7.6) 8.5 (8.5) 7.7 (6.8) 8.8 (9.1) (3.8) 5.6 (3.9) 7.3 (3.6) 7.3 (3.8) 27.1 (11.4) 20.8 (12.6) 26.1 (10.9) 27.1 (12.1)

33 Results Proportions with 12 month post-index date participation restrictions Propensity Score matched sample Knee Replacement Subjects (n=113) 70% 63% Non- knee replacement SxOA Subjects (n=113)

34 No difference between groups The knee replacement subjects had the same odds (OR 1.0, 95% CI 0.6,1.7) of participation restriction as the propensity-score matched Sx OA subjects.

35 Limitations Timing between pre-knee replacement and surgery and post-knee replacement and surgery differs and may be lengthy Caution interpreting proportions with participation restrictions in SxOA group, as these are matched to knee replacement group and thus have more severe symptoms

36 Conclusions of Matched Study Knee replacements do not necessarily decrease the risk of participation restrictions among persons with symptomatic knee osteoarthritis. One year may not be long enough follow-up time to assess participation restrictions among persons with knee replacement

37 Unclear Evidence Boston Other University studies Slideshow Title provide Goes Here evidence that participation improves 1,2 Does this achieve outcome thresholds? MOST data suggests that participation may get worse in some subjects Appears that pre-knee replacement participation status influences post-knee replacement participation status 2,3 Depressive symptoms, knee pain and age may be factors associated with participation restrictions 3 Evidence is unclear and needs to be looked at further

38 So where do we go next? Ms. Jones 60 years old RA for 20 years; good medication control She has chronic mild-moderate pain Ambulation limited to ¼ mile Employed Participates 2-3 times/week in community activities Mrs. Smith 60 years old RA 20 years; good medication control Chronic mild-moderate pain Ambulate ½ mile Works part time Rarely leaves her home

39 Intervention for Participation Limited evidence on rehabilitation programs post-knee replacement Those which exist address pain and physical function Need for more research on improving participation or decreasing participation restriction among persons post-knee replacement

40 Where are we and what s next? Boston Knee University replacements Slideshow Title Goes Here will occur at staggering rates Growing evidence that participation restrictions are common after knee replacement Beginning to explore factors associated with participation restrictions in this group of patients Area for increased focus of research

41 Acknowledgements David Felson, MD Michael LaValley, PhD Jingbo Niu, ScD. Tianzhong Yang, MS Julie Keysor, PT, PhD.

42 Thank you! Questions?